E&M Guidelines: HPI and Chronic Conditions

August 25th, 2014 / By Rebecca Caux-Harry

Last month, I blogged about the History of Present Illness (HPI) portion of an E&M note. The HPI section details the specifics of why the patient is seeing their physician. Prior to that, I wrote about the two sets of E&M guidelines, specifically the different exams within those guidelines to guide physicians and/or coders to select a level of care provided during that visit. This month, I’d like to dig into the point at which these two sets of guidelines converge: chronic conditions.

The 1995 E&M documentation guidelines stipulate that to support the higher levels of care, a provider must document four or more elements of the HPI. The 1997 E&M documentation guidelines added a chronic conditions option. These guidelines state that a provider could document the status of three or more chronic conditions rather than four or more elements of the HPI.

This option is particularly helpful for follow-up care where the physician is monitoring a patient’s disease process. Unfortunately, just as many providers or coders misunderstood this option as understood it. The key to this option is the status. A provider can’t point to a problem list as satisfying the HPI requirement, as the problem list doesn’t usually document the status of each issue. Additionally, problem lists are not updated by care providers regularly. So, to satisfy this requirement of the 1997 guidelines, a provider needs to document something like:  “Patient presents today for follow-up on her stable coronary artery disease, medication controlled stable hypertension and worsening hyperlipidemia.”  The provider has documented three chronic conditions and the status of each. Fantastic!  Now what??

Non-coders may not understand the question, but if you are a coder, a small smile is starting to appear on your face. The ‘status of 3 chronic conditions’ is an option only in the 1997 E&M guidelines. The provider goes on to document a complete Review of Systems, a comprehensive Past Family, Social and Medical History, and an eight system Physical Exam. That physical exam is system-based, which is only in the 1995 E&M documentation guidelines. Depending on where the care is being provided (think: the MAC adjudicating the claim) the coding of this record may or may not pose a problem. Some MACs (Medicare Administrative Contractors) had strict rules about combining the two sets of guidelines, others didn’t. For professional coders working in a Central Billing Office (CBO) and submitting claims to multiple MACs, they had to know whether they could ‘mix and match’ the guidelines. Talk about a headache!  (Unstable, but easily controlled with ‘consistent documentation guidelines’)

Thankfully, CMS came to our rescue last year. In September 2013, CMS officially stated that the chronic condition option could be used to satisfy the HPI documentation requirement regardless of exam guidelines followed. So, the example above no longer poses an issue. The status of three chronic conditions in a note using the 1995 exam guidelines is easily scored. Headache avoided, record coded compliantly. So, no need for soup this week, alphabet or otherwise.

Rebecca Caux-Harry, CPC, is the CodeRyte Product Specialist for Cardiology with 3M Health Information Systems.